Nicolas Fernandez et al., 2024: Surgeon, and Institution Characteristics Associated Surgical Preferences in the Pediatric KIDney Stone Care Improvement Network
Nicolas Fernandez 1 , Jonathan S Ellison 2 , Zi Wang 3 , Jing Huang 3 , David I Chu 4 , Renea Sturm 5 , Andrew A Stec 6 , Ryan S Hsi 7 , Wayland Wu 8 , Caleb Nelson 9 , Christina Ching 10 , Brian Augelli 11 , Matt Lorenzo 11 , Jing Bi-Karchin 11 , Gregory E Tasian 12
1Department of Surgery, Division of Urology, Seattle Children's Hospital, Seattle, WA.
2Children's Wisconsin and Medical College of Wisconsin, Milwaukee, WI.
3Department of Biostatistics, Epidemiology, and Informatics; Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA.
4Ann & Robert H. Lurie Children's Hospital of Chicago, Division of Urology. Chicago, IL.
5Mattel Children's Hospital, Department of Urology, University of California, Los Angeles, CA.
6Division of Urology, Nemours Children's Health, Jacksonville, FL.
7Department of Urology, Vanderbilt University Medical Center, Nashville, TN.
8Division Pediatric Urology, Cohen Children's Medical Center of New York, Zucker School of Medicine at Hofstra/Northwell, Long Island, NY.
9Department of Urology, Boston Children's Hospital, Harvard Medical School, Boston, MA.
10Kidney and Urinary Tract Center, Department of Pediatric Urology, Nationwide Children's Hospital, Columbus, OH.
11Department of Surgery, Division of Urology, The Children's Hospital of Philadelphia, Philadelphia, PA.
12Department of Biostatistics, Epidemiology, and Informatics; Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Department of Surgery, Division of Urology, The Children's Hospital of Philadelphia, Philadelphia, PA. Electronic
Abstract
Objective: To reveal barriers and opportunities to implement evidence for the management of pediatric kidney stone disease, we determined surgeon and institutional factors associated with preferences for the type of surgical intervention for kidney and ureteral stones.
Methods: We conducted a cross-sectional study of urologists participating in the Pediatric KIDney Stone Care Improvement Network (PKIDS) trial. Questionnaires ascertained strengths of urologists' preferences for types of surgery as well as characteristics of participating urologists and institutions. The outcome was the strength of preferences for ureteroscopy, shockwave lithotripsy, and percutaneous nephrolithotomy for four scenarios for which two alternative procedures are recommended by the AUA guidelines: (1) 2 cm kidney stone, (2) 9 mm proximal ureteral stone, (3) 1.5 cm lower pole kidney stone, (4) 1 cm nonlower pole kidney stone. Principal component analysis was performed to identify unique clusters of factors that explain surgical preferences.
Results: One hundred forty-eight urologists at 29 sites completed surveys. Stated preferences were highly skewed except for the choice between ureteroscopy and percutaneous nephrolithotomy for a 1.5 cm kidney stone. Shockwave lithotripsy ownership and local practice patterns most frequently associated with the strength of surgeons' preferences for the type of surgery. Principal component analysis revealed that three clusters of stone, patient, and heterogenous characteristics explained 30% of the variance in preferences.
Conclusion: There is wide variation in the strengths of preferences for surgical interventions supported by current guidelines that are partially explained by surgeon and institutional characteristics. These results reveal opportunities to develop strategies for guidelines that consider real-world drivers of care.
Urology. 2024 May:187:64-70. doi: 10.1016/j.urology.2024.02.040. Epub 2024 Mar 6. PMID: 38458327
Comments 1
This article presents the results of a questionnaire in which 148 urologists described how they would deal with four different stone situations encountered in children. The result was analyzed in view of treatment recommendations formulated and published by the Pediatric KIDney Stone Care Improvement Network in USA. Thereby it is necessary to consider that the outcome comprises theoretical rather than practical decisions based on a clinical problem with TWO treatment alternatives
One important conclusion is that the preferences for SWL were low despite recommendations in the AUA-guidelines at similar levels.
It is of note that stone-size, stone location, density and number of stones were important determinants for choice of treatment modality. Important was also the risk of complication. The re-imbursement, however, was rated low in this study which was surprising, but it is difficult to know whether the latter statement reflects reality in a purely theoretical model like this.
It is indeed surprising that SWL was not more commonly selected given the mobility of children and the transport capacity of the child’s ureter, because also fragments located in the lower calyces might have a good chance to be eliminated.
The enthusiasm for PCNL in children, with not very large stones, was surprising.
Hans-Göran Tiselius